Modified Single-Loop Reconstruction for Pancreaticoduodenectomy

Summary

The technique of modified single-loop reconstruction following pancreaticoduodenectomy separates pancreatic secretion from bile, thus reducing the severity of POPF without prolonging the duration of surgery.

Abstract

Modified single-loop reconstruction in pancreaticoduodenectomy separates pancreatic secretion from bile. It is performed in cases of high-risk pancreatic remnants to reduce the severity of postoperative pancreatic fistulas and moreover the overall postoperative morbidity. This reconstruction technique is characterized by an extra-long jejunal loop for the construction of the pancreaticojejunostomy and hepaticojejunostomy. The longer distance between these anastomoses and an additional jejuno-jejunostomy between the afferent and efferent limb of the hepaticojejunostomy separate the fluids and prevent backflow of bile towards the pancreaticojejunostomy. Thus, the secretions cannot activate each other and aggravate an existing anastomotic leakage. We observed a reduced rate of severe postoperative pancreatic fistulas after modified single-loop reconstruction compared to conventional single loop reconstruction. The technique is easy to perform, safe, and less time-consuming than a traditional double-loop reconstruction.

Introduction

Pancreaticoduodenectomy (PD) is considered a sophisticated surgical procedure. While mortality has decreased over the last decades, morbidity still remains high¹. The most frequent and feared complication is the postoperative pancreatic fistula (POPF), which occurs in over 20% of operations^2,3,4,5. POPF can lead to subsequent complications such as postpancreatectomy hemorrhage, delayed gastric emptying, intraabdominal abscess and sepsis. Increased hospital costs, prolonged hospital stay, and delayed initiation of chem....

Protocol

This protocol focuses on the reconstruction phase of PD using mSLR and follows the guidelines of the ethics committee of the Ruhr-University Bochum, Germany.

NOTE: Patients with a resectable tumor of the pancreatic head, the papillary region or severe refractory chronic calcifying pancreatitis underwent PD. Resectability was present if the tumor had less than 50 % contact to the peripancreatic arteries and did not infiltrate the portal vein or the superior mesenteric vein. Distant metastases in cases of adenocarcinomas were also contraindications for PD. The resection technique in PD is standardized and described in detail elsewhere

Results

Every patient undergoing PD underwent an investigation of the pancreatic tissue to evaluate the indication for mSLR. High-risk pancreatic remnants (i.e., soft pancreatic tissue and a tiny main pancreatic duct) were reconstructed using a modified single loop whenever possible.

We identified 50 patients with high risk pancreatic tissue and a small main pancreatic duct. All of them underwent mSLR. The mean age was 63 ± 13 years old. The male/female ratio was 17:33. Indications for surgery were ma.......

Discussion

To date, POPF contributes significantly to the postoperative morbidity following PD¹.

A mixture of bile and pancreatic juice can lead to mutual activation of both secretions, increasing their adverse effects on the PJ or the HJ^{9,13,14,15,16}. Cytotoxic activity of activated phospholipase A2, which converts bil.......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Alexis O XXL	Applied medical	C8405
Bauchtuch Grün 10x90	Nobatrast	603219	abdominal compress
Bauchtuch Grün 45x45	Nobatrast	607544	abdominal compress
GIA 60mm-3.8mm	Covidien/Medtronic	GIA6038S
GIA Loading Unit	Covidien/Medtronic	GIA6038L
OP-Flex Yankauer	Unomedical	34094182	suction device
Präpariertupfer-Set	Fuhrmann	32019	sterile swab
Schlinggazetupfer 30x40	Fuhrmann	32016	sterile swab
Telescopic Smoke Pencil	LiNA Medical	SHK-TSP-CL	electro cautery
Thermocover ECO	PEMAX	TC43-75EC2	bowel cover
Whipple-Set	Mölnlycke	97016042-00
Drainages:
Drainagebeutel	Coloplast	?	drainagebag
Silikon-Kapillardrainage	AsidBonz	551012	capillary drainage
Trichteransatz für T-Rohr	Rüsch	333169-000025	2,5 mm
T-Rohr nach Kehr	Rüsch	423600-000025	t-tube 2,5 mm
Sutures:
Ethiloop 2mm 2x45cm	Ethicon	EH387	loop
Mersilene 0 FSL	Ethicon	EH7637	fixation of the drainage
PDS 1 CT	Ethicon	PDP9234	suturing of the fascia
Vicryl 2-0 , 6x45cm	Ethicon	VCP1226	for ligature
Vicryl 2-0 SHplus, 8x70	Ethicon	VCP7850	for ligature
Vicryl 3-0 MH-1plus	Ethicon	VCP245	subcutaneous suture
Pancreatic anastomoses:
Prolene 5-0 c1	Ethicon	8890	6 x
PDS 5.0 RB-1plus	Ethicon	X1153	2 x Multipack
Prolene 4-0 RB-1	Ethicon	8871	2 x holding sutures
Hepaticojejunostomy:
Prolene 5-0 c1	Ethicon	8890	2 x holding sutures
PDS 5-0 c1	Ethicon	PDP1013	7 x
PDS 6-0 c1	Ethicon	PDP1012	1 x mucosa fixation sutures
Gastrojejunostomy:
PDS 4-0 SH-1 plus	Ethicon	X1154	1 x Multipack
Jejuno-Jejunostomy
Ligasure	Covidien	LS1520
PDS 5-0 RB-1 plus	Ethicon	X1153	1 x Multipack
Prolene 2-0 SH	Ethicon	8833	Vessel-suture, etc.
Prolene 3-0 SH	Ethicon	8832	Cystic duct, cystic artery
Prolene 4-0 RB-1	Ethicon	8871	2 mal suturing of the slit in the meso